Basic Goals
The goals of the first two weeks are simple and some of the most important to achieve the ideal result after ACL reconstruction. These goals include pain control, controlling swelling, regaining full knee range of motion (especially extension), and re-establishing quadriceps muscle control. All of these are dependent upon each other thus all are equally important. Achieving all of the above goals will lead to walking normally without crutches with-in the first two weeks. Physical therapy will be initiated on post op day 2.
Day 1-3:
Brace, Crutches, and Weight Bearing
You will wake up from surgery with a long leg brace that keeps your leg locked out straight. While the femoral nerve block is working there is no muscular control in that leg, which requires this brace be left on until the first therapy visit the day after surgery. So, to be clear, you must sleep in the brace the first night after surgery.
After the first night you do not have to sleep in the brace, but may if you are more comfortable with it on your leg.
It is very important for the brace to be on with your knee locked out straight when you are up and moving around. We, or your physical therapist, will unlock the brace when you regain good quadriceps muscle control (able to do 10 good straight leg raises). Typically, the TROM is opened to 30 degrees of flexion at your first post-operative visit and then 30 degrees each week until fully open. Crutches should always be used until you are walking normally without a limp. Weight bearing is allowed as tolerated from day 1.
Nobody likes using crutches and you may discontinue them when you can walk normally without a limp. This generally requires good pain control, good quadriceps muscle control, and full knee extension (you can get your knee completely straight).
Controlling Pain and Swelling
Controlling pain and swelling generally go hand in hand. Pain medicine, ice, and strict elevation with knee above heart and foot above knee may all help pain and swelling if used correctly.
The first night after surgery it is important to stay ahead of the pain and taking your pain medicine routinely; every 4-6 hours through the first night is recommended. I will discuss dosing schedule after surgery. Always eat a little something with your pain meds.
After that first night pain meds should only be taken as needed. Pain meds are a double-edged sword and you will feel better and eat better the sooner you can discontinue them for regular Tylenol.
Ice is important for pain control. You may apply ice to the leg for 20 minutes at a time every hour. You may do this as often as desired throughout the day. Generally, three to four good twenty-minute icings are recommended per day.
Do not overdo it the first several days as the more you are off your leg, with your leg elevated (knee above heart, foot above knee) doing the simple things described above the better your pain and swelling will be controlled. If swelling is problematic and preventing range of motion or quadriceps function after the first week an aspiration of the swelling from the knee joint may be required.
**Range of Motion and Quadriceps Control**
Regaining full and normal range of motion after ACL reconstruction is absolutely the most important parameter predicting an ideal result and return to normal daily life and athletic functional activities. Everything discussed above is important to achieve this result and to some degree progressing into more aggressive physical therapy and exercise programs should be delayed until normal range of motion has been obtained. Extension stretching is important to begin immediately after surgery.
Extension stretching should begin immediately in the post-operative period. This is best accomplished by rolling up towels to a diameter of 10-12 inches and propping your heel up on the rolled-up towel for 5-10 minutes out of every hour you are awake until it is easy to completely straighten your knee. This is important with ALL ACL procedures not just patellar tendon grafts.
Re-establishing quadriceps muscle function is critical to re-gaining normal extension and in preventing scarring. If you cannot do good straight leg raises within the first week make sure you or your PT lets us know. Quadriceps function also allows you to walk unsupported without crutches so the sooner the quadriceps is working the sooner you will have normal extension and get off crutches.
Summary
Philosophically during the first two weeks after ACL reconstruction the focus should be on the little things that are discussed above. The goal of walking normally, off crutches, with full range of motion of the surgical knee will put you in position to begin the exercise phase of recovery from ACL reconstruction. This is where it gets fun and you will begin to see a light at the end of the tunnel for returning to your normal activities. Patience and focus on the little things are the mantra for the first two weeks and your fastest path to full recovery.
If you have any problems or questions please do not hesitate to contact our office.
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